1. Intern Case Presentation Eye Probs
Heidi Rogers
PGY-1
5/29/15

2. CC: Eye problem
HPI: 32 yo male who presents to the ED for 5 day history left eye pain and redness.

3. Red Eye: Important Questions to Ask
Blurred or decreased vision
Pain
Photophobia
Hx of trauma
Itch: allergic conjunctivitis
Previous episode
Iritis, dendritic ulcer
Contact Lens wearer: corneal infections
Discharge
Recent URI: viral conjunctivitis
Hx of eye surgery
endophthalmitis

4. EXAM Test vision and pupils Examine cornea for foreign body or ulcer
Evert eyelids
Foreign body
Ophthalmoscopy
If slit lamp available:
Examine anterior chamber and assess depth
Stain cornea with fluorescein and examine with blue light
Looking for dendrite or corneal abrasion
Check intra-ocular pressure
Normal is mmHg

5. Pattern of Redness
Ciliary injection: redness most prominent around peripheral cornea.
Iritis, acute glaucoma
Conjunctival injection: Diffuse redness of entire conjunctiva
Conjunctivitis
Subconjunctival hemorrhage: thin continuous layer of BRB over white sclera

6. Conjunctival Injection
Subconjunctival Hemorrhage
Ciliary Injection

7. Important points for red eye
If patient has decreased vision, pain, or photophobia they will need urgent (same-day) referral to ophthalmology
Not every red eye is “conjunctivitis”
Never prescribe steroid eye drops unless ophthalmology has given the okay
Only prescribe antibiotic drops for bacterial conjunctivitis: 2 red eyes, pus-like discharge, no change in vision, no pain/photophobia

8. HPI continued
Patient woke up 5 days ago with red, throbbing, watery left eye. He reports photophobia and blurry vision of his left eye only. No trauma to eye. Not a contact lens wearer. He has had one similar episode in the past affecting his other eye. He has used OTC eye artificial tears and ibuprofen which has not significantly improved pain/redness. Associated symptoms include left –sided temporal headache, sore throat, subjective fever/chills, diffuse myalgias.

9. Social PMH ROS PSH: None Medications: None Allergies: None FH:
no alcohol/tob/drugs
Security guard
One sexual partner, may have had an STD
ROS
Positive: fatigue, fever, weakness, sore throat, muscle aches, headache, cough
Negative: painful urination, genital lesions/discharge, joint pain/stiffness
PMH
DM2
HTN
Diverticulitis
Previous episode red eye
PSH: None
Medications: None
Allergies: None
FH:
Dad – DM2, cancer
Mom: DM2, cancer
No hx rheumatologic diseases  

10. Physical Exam
Vitals: T 98.5 °F, HR 105, BP 164/104 mmHg, RR 18, SpO2 97 %
General: Well-developed, NAD
HEENT: Normocephalic and atraumatic.
Cardiovascular: Normal rate, regular rhythm, no murmurs
Pulm: CTAB, no wheezes/crackles/rhonchi
Abdomen: normal active BS, soft, NTTP
Extremities: +2/4 radial and DP pulses, no edema, no cyanosis
Skin: warm, dry, no rashes
Neuro: A&O x 3, no neuro deficits

11. Eye Exam
IOP: OD 13, OS 10
Vision without correction OD 20/20, OS 20/25
R eye: PERRL, no discharge/injection/foreign bodies, no lesions with
L eye: PERRL, serous discharge, no foreign body, + ciliary injection. Slit lamp: cells and flare, inferior fine keratic precipitates
No lesions appreciated with fluorescein stain.

13. Work-up in ED CBC: CMP ESR 55 CXR – negative for acute process
WBC 13.0
Hgb 15.6
Hct 43.3
187
CMP
Na 134
K 4.3
Cl 99
Bicarb 23
Glucose 478
AST/ALT 30/35
Calcium 10.0
Albumin 3.9
ESR 55
CXR – negative for acute process

14. Anterior Uveitis (Iritis/Iridocyclitis)

16. Background
Most common form of intraocular inflammation and painful red eye
Inflammation of the anterior portion of the uvea or middle portion of the eye. Anterior portion includes iris and ciliary body.
Iritis: Inflammation of the iris
Iridocyclitis: Inflammation of the iris and the ciliary body
Subdivided into 2 broad categories: granulomatous and non-granulomatous

17. Granulomatous Non-granulomatous
More likely to be a systemic disease process
Syphilis, Lyme disease, TB, Sarcoidosis
Can be bilateral
Non-granulomatous
Idiopathic, associated with HLA-B27 allele, trauma, JIA
Unilateral

18. Symptoms Visual acuity normal or slightly decreased Ciliary injection
Eye pain: dull and aching
Pain may be referred to temple/peri-orbital region
Consensual photophobia
Pain in affected eye when light shone in opposite eye
Sometimes constricted pupil

19. Signs Low IOP most common
Cells and flare in anterior chamber: Breakdown of blood-ocular barrier 2/2 inflammation WBC and protein accumulation in aqueous humor
Keratic precipitates: Clusters of WBC on the endothelium
Non-granulomatous
Stellate-shaped: Uniformly spread over entire corneal epithelium
Herpetic, CMV
Fine: small, inferior half of cornea; idiopathic, HLA-B27 associated uveitis, trauma, JIA
Granulomatous:
“Mutton-fat”, large and greasy appearance
Located mostly on inferior cornea

20. Cell and Flare

21. Stellate KPs

22. Fine KPs

23. Granulomatous KPs

24. Differential Diagnosis
Posterior uveitis
with spillover into anterior chamber
Traumatic iritis
Contact Lens-associated red eye
Ocular Rosacea
Posner-Schlossman syndrome
Recurrent episodes high IOP and
minimal inflammation
Tumor
Young: retinoblastoma
Elderly: lymphoma
All: metastatic disease
Infectious endophthalmitis

25. Etiology Idiopathic: 30% of cases Infectious causes:
Herpes zoster, herpes simplex, CMV, toxoplasmosis, syphilis, tuberculosis, Lyme dz, West Nile virus, Leprosy, HIV-1
Systemic inflammatory diseases:
Spondyloarthritis, sarcoidosis, JIA, psoriatic arthritis, IBD, multiple sclerosis, Behcet’s disease, SLE, systemic vasculitis, Sjogren’s
Drugs
Rifabutin, Cidofovir, fluoroquinolones, bisphosphonates, cancer immunotherapy

26. Work-up/Diagnosis Detailed history and ROS
Ask about ocular trauma, back stiffness, joint pain, rashes, dysuria, STDs, TB exposure, bloody diarrhea
Ocular exam including IOP and slit-lamp exam
Anterior chamber with cells and flare, KPs
Lab work
No lab work if: 1st episode, mild, unilateral, non-granulomatous, H&P not suggestive of systemic disease, findings classic for a specific diagnosis
If bilateral, granulomatous, recurrent, and history is nonspecific then consider: RPR or VDRL, FTA-ABS, PPD, CXR, ACE, Lyme titer, ESR, HLA-B27

27. Treatment Initiate therapy within 24 hours Topical glucocorticoids
Prednisolone acetate 1%
Long-acting cycloplegic to help relieve pain and photophobia
Cyclopentolate, scopolamine, or atropine
Treat underlying cause
Uveitis that is resistant to topical therapy: oral glucocorticoids, immunomodulators (methotrexate, azathioprine, infliximab)

28. Back to our patient
Evaluated by ophthalmology the same-day and diagnosed with 2nd episode iridocyclitis
Prescribed: prednisolone acetate 1% drops 4 times daily
RTC within 1 week
Work-up so far is negative: CXR, RF, HLA-B27, ACE, ANA, VDRL, FTA-ABS

29. References
The Red Eye, Chapter 4
Up-To-Date
Uveitis: Etiology, clinical manifestations, and diagnosis
Uveitis: Treatment
Evaluation of the red eye
Emedicine
Uveitis, Anterior, Nongranulomatous Clinical Presentation
Uveitis, Anterior, Granulomatous Clinical Presentation